Africa: Global Fund Results

Editor's Note

According to a new report from the Global Fund to Fight AIDS, TB,
and Malaria, the Fund's efforts have contributed to saving an
estimated 4.9 million lives by December 2009. The coming years will
see even more results, as half of the total disbursements by the
Global Fund were delivered in 2008 and 2009. Much of the US$ 5.4
billion of financing approved in Rounds 8 and 9 will reach
countries in 2010 and 2011, and will continue to significantly
boost health outcomes.

This AfricaFocus Bulletin contains the executive summary of the
document Innovation and Impact and a summary of one of the
additional documents, which analyzes the mixed results of African
government pledges to provide additional funding. That report finds
that the percentage of the average government expenditure on
health, as a percentage of total government expenditure, rose only
marginally from 8.8% in 2001 to 9.0% in 2007, despite the 15%
commitment of the Abuja Declaration. But a number of countries
showed substantially greater increases. By 2007 three countries had
met the 15% target (Djibouti, Botswana and Rwanda).

Another AfricaFocus Bulletin, sent out by e-mail today and
available on the web at http://www.africafocus.org/docs10/hiv1007a.php, contains excerpts
from a UNAIDS press release and from the 2010 UNAIDS Outlook
report, outlining new recommendations for "Treatment 2.0" as well
as noting progress in HIV/AIDS prevention, particularly among young
people in Africa.

The Global Fund 2010

Executive Summary

1. Every day, programs supported by the Global Fund save at least
3,600 lives, prevent thousands of new infections and alleviate
untold suffering.

2. The Global Fund to Fight AIDS, Tuberculosis and Malaria is a
public-private partnership established in 2002 to mobilize and
intensify the international response to three global epidemics and
thereby help achieve the Millennium Development Goals (MDGs). From
its founding through December 2009, the Global Fund Board approved
proposals totaling US$ 19.2 billion, and disbursed US$ 10 billion
for HIV, tuberculosis (TB) and malaria control efforts. To maximize
impact, every dollar donated goes to fund programs in country. The
Global Fund has no country offices, and its operating expenses are
almost entirely covered by the interest earned on the Trustee
account at the World Bank.

3. The results and impact outlined in the report are the
achievements of all the partners that collaborate as part
of the Global Fund model. The success of the Global Fund
relies on the financial pledges of donors, the technical
guidance of - and collaboration with - multilateral partners, and
particularly the management and implementation of programs by
in-country partners including governments, civil society
organizations and the private sector.

4. HIV. At the end of December 2009, programs financed
by the Global Fund were providing antiretroviral therapy
(ART) to 2.5 million people. Approved HIV proposals have
totaled close to US$ 10.8 billion covering 140 countries.
The Global Fund is estimated to have contributed about one-fifth of
all disbursements by bi- and multilaterals for the HIV response in
low- and middle-income countries in 2008. In addition to providing
ART, programs funded by the Global Fund have also distributed 1.8
billion male and female condoms and have provided 790,000
HIV-positive pregnant women with treatment to prevent
mother-to-child transmission of HIV, as well as 4.5 million basic
care and support services to orphans and other children made
vulnerable by AIDS, and 105 million HIV counseling and testing
sessions. There is a growing body of evidence showing that Global
Fund financing - alongside that of other financiers - has resulted
in declines in AIDS mortality in countries in which provision of
ART has been scaled up rapidly, accompanied by other significant
impacts, such as improved survival and productivity of key
professionals and other workers, and systemwide improvements in
health care delivery.

5. Tuberculosis. Through 2009, programs funded by the Global Fund
have provided treatment to 6 million people who had active TB. The
Global Fund provides 63 percent of the external financing for TB
and multidrugresistant TB (MDR-TB) control efforts in low- and
middle-income countries. Approved TB proposals have totaled close
to US$ 3.2 billion covering 112 countries, contributing 48 percent
of the projected coverage required to achieve the Stop TB
Partnership targets for the detection and treatment of new
smear-positive TB cases. TB programs supported by the Global Fund
have also provided 1.8 million TB/HIV services. In many countries
in which the Global Fund supports programs, TB prevalence is
declining, as are TB mortality rates.

6. Malaria. By the end of 2009, Global Fund-supported
programs had distributed 104 million insecticide-treated
nets (ITNs) to prevent malaria. They also supported indoor
residual spraying of insecticides in dwellings more than
19 million times and treated 108 million cases of malaria in
accordance with national treatment guidelines. Approved
malaria proposals have totaled US$ 5.3 billion covering 83
countries. In 2008, the Global Fund contributed 57 percent of
international disbursements for malaria control. Global Fund
investments have played a critical role in introducing and
expanding coverage of novel, effective malaria treatments in many
countries where drug resistance to older treatments is high. In
conjunction with re-energized national and international efforts to
combat malaria, increased Global Fund financing is having a
substantial impact on malaria morbidity and mortality worldwide,
with an increasing number of countries reporting a reduction in
malaria deaths of more than 50 percent.

7. The Global Fund supports community-based interventions.
Since 2003, these efforts have delivered 138 million
community outreach prevention services for at least one
of the three diseases and provided 11.3 million "person-episodes"
of training for health and community workers.

8. These combined efforts saved an estimated 4.9 million lives by
December 2009 and restored hope for the 33 million people living
with HIV, the hundreds of millions of people who contract malaria
or who are at risk each year, and the 9.4 million who contract
active TB annually. The coming years will see even more results, as
half of the total disbursements by the Global Fund were delivered
in 2008 and 2009. Much of the US$ 5.4 billion of financing approved
in Rounds 8 and 9 will reach countries in 2010 and 2011, and will
continue to significantly boost health outcomes.

Having a wider impact: Strengthening health systems and
contributing to progress on the Millennium Development Goals

9. The Global Fund investments to combat HIV, TB and malaria are
having a much wider impact - beyond individuals, their families and
communities. They are major investments in health systems -
bolstering infrastructure, strengthening laboratories, expanding
human resources, augmenting skills and competencies of health
workers, and developing and supporting monitoring and evaluation
(M&E) activities. These enhancements, in turn, improve the
sustainability of services, increase national capacity to expand
programs further and increase countries' ability to improve
services for other health issues. Ultimately, the investments
translate into a healthier population and increased productivity,
enabling countries to further their development.

10. These investments have helped accelerate progress towards the
MDGs by contributing directly to MDGs 4, 5, 6 and 8, and indirectly
to the others. The US$ 19.2 billion of approved investment by the
Global Fund is a direct contribution to MDG 6 ("Combat HIV/AIDS and
malaria and other diseases"). In addition, major contributions have
also been made to MDG 4 (on child mortality) and MDG 5 (on maternal
mortality) by reducing the largest causes of mortality among women
and children. This is particularly the case in sub-Saharan Africa,
where HIV, TB and malaria are responsible for 52 percent of deaths
among women of childbearing age and malaria alone accounts for 16
to 18 percent of child deaths.

Achieving results and promoting equity

11. The Global Fund's innovative financing model was designed to
respond quickly and effectively to the tremendous need for funding
in the countries with the heaviest burdens of AIDS, TB and malaria,
while ensuring transparency and broad accountability to donors and
recipients. This model has continued to evolve, and in 2009 it
tested new ways to strengthen country ownership and governance,
increase access to lifesaving medicines and other health products,
and promote health equity.

12. Equitable access to services is fundamental to the mission of
the Global Fund. In making grants, great weight is assigned to each
country's needs, as measured by indicators such as disease burden
and poverty level. The Global Fund also works to ensure that the
programs it finances address the needs of the poorest, at-risk and
marginalized groups, for instance with its new strategies on gender
equality and sexual minorities. Further, it has become the world's
leading funder of harm reduction services for people who inject
drugs, with substantial investments in 42 countries.

13. Between 2005 and 2009, nearly four out of five assessed grants
were performing well. Currently, TB grants are the best performers
and civil society organizations the best performing Principal
Recipients.

Continuing to learn, improve effectiveness and innovate

14. The Global Fund always seeks to learn, improve and innovate
through its operations, partnerships and valuations. One key
opportunity for learning comes from the engagement of different
constituencies in Global Fund governance - governments, civil
society, the private sector, affected communities and bilateral and
multilateral agencies.

15. The Global Fund actively contributes to global efforts
to improve aid effectiveness, especially in the area of managing
for results, by playing a leading role in monitoring effectiveness
and sharing experiences with performance-based funding.

16. Within the Global Fund, the Board, the Board committees, the
Executive Management Team, the Technical Evaluation Reference Group
and the Office of the Inspector General help identify key areas of
the organization's programs and business model in need of
evaluation or improvement. The continuous attention to evaluation
and learning helps the Global Fund maximize its responsiveness,
effectiveness and cost-effectiveness.

17. Ensuring value for money at every stage of the financing chain
is a critical priority for the Global Fund. One of the focus areas
is to develop and promote, with partners, standardized methods for
countries to measure the efficiency and effectiveness of key HIV,
TB and malaria services. The comprehensive performance review which
occurs by year two of each grant also contributes to value for
money by allowing for the reallocation of funds from poorly
performing grants to better-performing grants as well as for the
identification of efficiency gains. In 2009 alone, nearly US$ 1
billion was freed up for funding new grants. Voluntary pooled
procurement is reducing the cost and improving the quality of
pharmaceuticals and health products, and collaboration with
technical partners is assessing the efficiency of service delivery
models in order to expand and optimize access to lifesaving
interventions.

18. Through its portfolio of grants in 144 countries,
the Global Fund has developed and is strengthening data
analysis of unit costs for HIV, TB and malaria services.
This analysis will institute savings, reveal best practices and
waste, and assist in assessing resource-need estimates
in future grant applications.

Maintaining the positive momentum for achieving results and impact

19. The Global Fund is realizing the extraordinary vision
of its founders, donors and implementers: it has dramatically
intensified the fight against HIV, TB and malaria while
contributing to improving health systems and to progress on
achieving the MDGs. Virtual elimination of mother-to-child HIV
transmission globally by 2015 can be achieved. Massive scale-up of
HIV prevention programs and of provision of ART continues, though
universal access to comprehensive and evidence-based HIV
prevention, treatment, care and support remains distant. Prevalence
of TB has significantly decreased over the last decade and the
international target of halving TB prevalence could be met by 2015.
Unprecedented coverage with ITNs and effective novel treatments
have made great inroads in combating malaria. The rapid scale-up of
prevention, treatment, care and support for these three pandemics
has meant hope and - as the results in this report testify - a
positive impact on millions of lives.

20. Such unprecedented progress would not have been possible
without the support of donors and partner organizations. In the
coming years, continued, substantial increases in long-term
financial commitments by donors will be needed to consolidate these
gains and to reach the MDGs by 2015 and universal coverage of HIV,
TB and malaria services. 2010 is a year that should inspire
extraordinary commitments from the public and private sectors to
safeguard and build upon the already substantial achievements made
over the past decade.

African Countries Face Major Challenges in Bid to Increase Domestic
Spending on Health

African governments have not lived up to their commitment in the
Abuja Declaration to allocate 15% of their annual budgets to health
expenditure.

Furthermore, short- to medium-term domestic funding for health in
low-income countries in Africa will not be enough to provide the
basic package of interventions required by the population, even if
African governments were to increase spending on health in line
with their commitments in the Abuja Declaration. Any increase in
funding will need to draw upon all sources, domestic and
international, until the tax bases of African countries grow
sufficiently to assume a larger share of the costs.

These are three of the conclusions of "Trends in Development
Assistance and Domestic Financing for Health in Implementing
Countries," a report prepared by the Global Fund. The report
examined health expenditures in 52 African countries (37 low-income
and 15 middle-income) and in 20 non-African middle-income
countries.

In the 2001 Abuja Declaration, African countries agreed to allocate
at least 15 percent of their annual budgets to the health sector.
From the perspective of the Global Fund, this is an important
commitment because the programmes currently supported by the Global
Fund can only become sustainable if implementing countries
gradually assume a bigger share of the burden of financing these
programmes.

An examination of national health account data revealed that for
all 52 African countries, the average government expenditure on
health, as a percentage of total government expenditure, rose only
marginally from 8.8% in 2001 to 9.0% in 2007, despite the 15%
commitment of the Abuja Declaration. Twenty-five countries recorded
increases in the percentage of total government expenditures
devoted to health between 2001 and 2007; the remaining 27 countries
reported reductions.

Some countries fared better than others. While, in 2001, none of
the countries were spending 15% or more of their national budgets
on health, by 2007 three countries had met the 15% target
(Djibouti, Botswana and Rwanda).

In addition, three African countries (Liberia, Malawi and Burkina
Faso) had surpassed the 15% target for at least some of the years
between 2001 and 2006 (though not in 2007).Over the period
2001-2007, 10 countries (Benin, Botswana, Burkina Faso, Djibouti,
Gabon, Malawi, Mali, Namibia, Rwanda, and Tanzania) consistently
allocated, on average, above 12% of total government expenditures
to health. This list includes both middle- and low-income
countries. At the opposite end of the spectrum, the average
allocations for health for this period in Angola, Guinea, Eritrea,
Guinea Bissau and Nigeria was consistently less than 5% of total
government expenditure.

In terms of how the data breaks down by sub-region within Africa,
between 2001 and 2007, spending on health (as a percentage of the
national budget) rose noticeably in East Africa, but declined
significantly in North Africa, with little change in West, Central, and
Southern Africa.

The data shown above relate to health spending as a percentage of
national expenditures. The report from the Global Fund also looked
at other ways to analyse health expenditures in Africa. The
following are some of the findings:

Health expenditures as a percentage of GDP: Total expenditure on
health as a percentage of GDP rose in nearly two-thirds of the
African countries between 2001 and 2007, with Namibia, Zimbabwe,
Democratic Republic of Congo, Rwanda and Burundi all recording
increases of 30% or more. Half of the 52 countries examined devoted
at least 5% percent of their GDP to health. (In comparison, the
total expenditure on health as a percentage of GDP in the WHO South
East Asia and Eastern Mediterranean regions was 3.4% and 4.5%,
respectively.)

Funding from external sources as a percentage of total health
expenditures: The average external funding proportion of total
health expenditure in all 52 African countries grew from a level of
15.3% in 2002 to 20.1% in 2006. Thirty seven African countries
recorded increases in external contributions over this period.

Per capita total expenditure on health: The per-capita total
expenditure on health in the WHO African Region in 2006 was $111.
However, if the middle-income countries are removed from the
calculation, the amount drops to $65. This compares to $85 for the
WHO South East Asia Region and $791 globally.

The report found that there is no significant difference in the
allocation of national budgets to health between the African
middle-income countries and the middle-income countries from other
regions selected for the study. In both sets of countries,
government expenditure on health as a percentage of total
government expenditure is clustered between 8% and 12%.

The report said that "while external aid has its risks in terms of
long term sustainability and aid dependency, the dilemma faced by
the African lower-income countries is the absence of effective
alternatives. Domestic tax bases and alternative revenue sources
remain modest in Africa and in lower-income countries elsewhere."

The report said that although several African countries have
increased their financial resources following the Abuja
Declaration, they still do not have enough money to fund programs
at levels that will enable them to attain universal access targets
and the Millennium Development Goals. In addition, the report said,
"even a significant push by African countries to achieve the 15
percent target would lead to only a marginal increase in their
per-capita health expenditures, particularly in the countries
already devoting above-average proportions of their resources to
health."

Finally, the report concluded that "significant development
assistance for health flows to African countries will remain
critical for the countries to attain the required additional
per-capita expenditure on health that is needed to scale up
national programs."

AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
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